Extra-corporeal membrane oxygenation for the post-cardiotomy patient.

Extra-corporeal membrane oxygenation remains the last resort in keeping patients alive in those with profound cardiogenic shock following percutaneous interventions or open surgery on the heart. No guidelines exist on the management of patients on such a device despite a high mortality. We attempt to highlight some universal principles that would be relevant to the current practice of those exposed to this challenging field.

The effect of deep hypothermia on the human pulmonary circulation.

OBJECTIVE: Acute rises in pulmonary artery pressures following complex cardiac surgery are associated with high morbidity and mortality. We hypothesised that periods of deep hypothermia predispose to elevated pulmonary pressures upon rewarming. We investigated the effect of this hypothermic preconditioning on isolated human pulmonary arteries and isolated perfused lungs. METHODS: Isometric tension was measured in human pulmonary artery rings (n=24). We assessed the constriction and dilation of these arteries at 37 °C and 17 °C. Isolated perfused human lung models consisted of lobes ventilated via a bronchial cannula and perfused with Krebs via a pulmonary artery cannula. Bronchial and pulmonary artery pressures were recorded. We investigated the effect of temperature using a heat exchanger. RESULTS: Rewarming from 17 °C to 37 °C caused a 1.3 fold increase in resting tension (p<0.05). Arteries constricted 8.6 times greater to 30 nM KCl, constricted 17 times greater to 1 nM Endothelin-1 and dilated 30.3 times greater to 100 µM SNP at 37 °C than at 17 °C (p<0.005). No difference was observed in the responses of arteries originally maintained at 37 °C compared to those arteries maintained at 17 °C and rewarmed to 37 °C. Hypothermia blunted the increase in pulmonary artery pressures to stimulants such as potassium chloride as well as to H-R but did not precondition arteries to higher pulmonary artery pressures upon re-warming. CONCLUSIONS: Deep hypothermia reduces the responsiveness of human pulmonary arteries but does not, however, precondition an exaggerated response to vasoactive agents upon re-warming.

Are initial valve operations in octogenarians still high-risk in the current era?

BACKGROUND AND AIM OF THE STUDY: The average age of cardiac patients continues to increase. As more octogenarians undergo surgery during the current era, the outcome of valve surgery was investigated to determine the operative risk in these patients. METHODS: Among 350 patients aged > or = 80 years who had initial surgery between 1998 and 2006, a total of 188 (105 females, 83 males) underwent valve surgery. A prospective analysis was conducted of the collected data. RESULTS: The median age of patients was 82 years (IQR: 81-84 years), and over half of them presented with severe symptoms (NYHA class III/IV; n = 96), controlled heart failure (n = 108), hypertension (n = 101) and coronary artery disease (n = 108). Concomitant coronary artery bypass grafting (CABG) was performed in 89 cases (47%). Perioperative hemodynamic support with inotropes was common (47%). Hospital death after isolated aortic valve replacement (AVR) (n = 89) and mitral valve replacement (MVR) (n = 10) occurred in four patients (4.5%, median additive EuroSCORE 9.0%) and one patient (10%, median additive EuroSCORE 9.8%), respectively. Concomitant CABG led to a doubling of the operative mortality which, for AVR, declined from 5.4% to 3.8% during the latter half of the study period. The median length of stay was 24 h (IQR 21-44 h) in the intensive care unit, and 10 days (IQR 7-14 days) postoperatively. The risk factors for operative mortality were urgent/emergent surgery (HR 3.27, 95% CI 1.12-9.58, p = 0.03), preoperative gastrointestinal disease (HR 3.15, 95% CI 1.12-8.9, p = 0.03), left ventricular ejection fraction <0.30 (HR 4.37, 95% CI 1.29-14.82, p = 0.02), and ischemic time (HR 1.04, 95% CI 1.004-1.07, p = 0.02). CONCLUSION: Elective isolated AVR can be performed with modest operative risk in octogenarians with good left ventricular systolic function. Additional procedures impose long ischemic times and increase the operative risk, as does MVR. Strategies to minimize the complexity and extent of surgery should benefit these patients.

Early neurological complications after coronary artery bypass grafting and valve surgery in octogenarians.

OBJECTIVE: To determine the incidence and risk factors for neurological events complicating cardiac surgery, and the implications for operative outcome in octogenarians. METHODS: Of 6791 who underwent primary on-pump CABG and/or valve surgery from 1998 through 2006, 383 were aged > or =80 years. Neurological complications, classified as reversible or permanent, were investigated by head CT scan in patients who did not recover soon after an event. RESULTS: There were more females (47% vs 26%, p<0.0001) among octogenarians (n=383, median age 82 years) than among younger patients (n=6408, median age 66 years). Controlled heart failure, NYHA class III/IV and chronic obstructive pulmonary disease were more prevalent in octogenarians while preoperative myocardial infarction was predominant in younger patients. Octogenarians were at higher operative risk (median EuroScore 6 vs 2, p<0.0001). Operative procedures differed between octogenarians and younger patients (p<0.0001); respective frequencies were 45% vs 77% for CABG, 26% vs 10% for AVR, and 23% vs 6% for AVR+CABG. Mortality was higher for octogenarians (8.9% vs 2.1, p<0.0001). Early neurological complications observed in 3.9% of the entire study population were mostly reversible (3.2%). Age > or =80 years (odds ratio [OR] 2.82, 95% confidence interval [CI] 1.89-4.21, p<0.0001), prior cerebrovascular disease (OR 2.23, 95% CI 1.56-3.18, p<0.0001), AVR+CABG (OR 2.92, 95% CI 1.60-5.33, p<0.0001) and MVR+CABG (OR 4.77, 95% CI 2.10-10.85, p<0.0001) were predictive of neurological complications. More octogenarians experienced neurological events (p<0.0001): overall 12.8% vs 3.4%, reversible 11.5% vs 2.8%, permanent 1.3% vs 0.6%. Among octogenarians, neurological complication was associated with elevated operative mortality (18% vs 8% for those without neurological complication, p=0.03), and prolonged ventilation, intensive care stay and hospitalisation. Predictors of neurological complications in octogenarians were blood and/or blood product transfusion (OR 3.60, 95% CI 1.56-8.32, p=0.003) and NYHA class III/IV (OR 7.6, 95% CI 1.47-39.70, p=0.02). CONCLUSION: Octogenarians undergoing on-pump CABG and/or valve repair/replacement are at higher risk of neurological dysfunction, from which the majority recover fully. The adverse implications for operative mortality and morbidity, however, are profound. Blood product transfusion which has a powerful correlation with neurological complication should be reduced by rigorous haemostasis with parsimonious use of sealants when appropriate.

Is post-sternotomy percutaneous dilatational tracheostomy a predictor for sternal wound infections?

OBJECTIVE: Early post-sternotomy tracheostomy is not infrequently considered in this era of percutaneous tracheostomy. There is, however, some controversy about its association with sternal wound infections. METHODS: Consecutive patients who had percutaneous tracheostomy following median sternotomy for cardiac operation at our institution from March 1998 through January 2007 were studied, and compared to contemporaneous patients. We identified risk factors for tracheostomy, and investigated the association between percutaneous tracheostomy and deep sternal wound infection (mediastinitis) by multivariate analysis. RESULTS: Of 7002 patients, 100 (1.4%) had percutaneous tracheostomy. The procedure-specific rates were: 8.6% for aortic surgery, 2.7% for mitral valve repair/replacement (MVR), 1.1% for aortic valve replacement (AVR), and 0.9% for coronary artery bypass grafting (CABG). Tracheostomy patients differed vastly from other patients on account of older age, severe symptoms, preoperative support, lower ejection fraction, more comorbidities, more non-elective and complex operations and higher EuroScore. Risk factors for tracheostomy were New York Heart Association class III/IV (OR 6.01, 95% CI 2.28-16.23, p<0.0001), chronic obstructive pulmonary disease (OR 1.84, 95% CI 1.01-3.37, p=0.05), preoperative renal failure (OR 3.57, 95% CI 1.41-9.01, p=0.007), prior stroke (OR 3.08, 95% CI 1.75-5.42, p<0.0001), ejection fraction<0.30% (OR 2.73, 95% CI 1.23-6.07, p=0.01), and bypass time (OR 1.008, 95% CI 1.004-1.012, p<0.0001). The incidences of deep (9% vs 0.7%, p<0.0001) and superficial sternal infections (31% vs 6.5%, p<0.0001) were significantly higher among tracheostomy patients. Multivariate analysis identified percutaneous tracheostomy as a predictor for deep sternal wound infection (OR 3.22, 95% CI 1.14-9.31, p<0.0001). CONCLUSIONS: Tracheostomy, often performed in high-risk patients, may further complicate recovery with sternal wound infections, including mediastinitis, therefore, patients and timing should be carefully selected for post-sternotomy tracheostomy.

The impact of symptom severity on cardiac reoperative risk: early referral and reoperation is warranted.

BACKGROUND: Operative mortality is comparatively higher for coronary artery bypass grafting (CABG) or valve reoperations. Studies of reoperative risk have focussed on surgical techniques. We sought to determine the risk and predictors of poor outcome in current practice, and the influence of preoperative symptoms. METHOD: For every redo patient (n=289), we selected the best-matched pair of patients who underwent a primary operation (n=578) between 1998 and 2006. Matching variables were age, gender, left ventricular ejection fraction (LVEF) and type of operation. Poor outcome was defined as operative mortality or major morbidity. RESULT: Median age was 68 (interquartile range 62-73) years and 28% were female for both groups. Severe symptoms and cardiac morbidity dominated the presentation of redo patients. CABG (53%), valve repair/replacement (34%) and combined CABG and valve (12%) were performed with overall operative mortality of 6.6% (median additive EuroScore 7.0) for redo versus 1.6% (median additive EuroScore 4.0) for primary groups (p<.0001). Whereas no significant difference was observed between primary (1.6%) and redo CABG (3.9%, p=.19), valve reoperations had higher operative mortality (9.6% vs 1.5%, p<.0001). Major complications occurred more frequently after redo valve compared to primary valve operations (28% vs 14%, p=.001). Reoperation (odds ratio [OR] 1.26, 95% confidence interval [CI] 0.66-2.42, p=.48) was not a predictor of major adverse event after CABG or valve surgery. Determinants of poor outcome after valve reoperations were New York Heart Association class III/IV (OR 6.86, 95% CI 2.29-12.11, p=.03), duration of extracorporeal circulation (OR 1.17, 95% CI 1.02-1.35, p=.03) and mitral valve replacement (OR 4.07, 95% CI 1.83-36.01, p=.04). The predictors of major adverse events after redo CABG were congestive heart failure (OR 1.85, 95% CI 1.04-8.98, p=.006) chronic obstructive pulmonary disease (OR 17.5, 95% CI 1.87-35.21, p=.05) and interval from prior surgery (OR 1.37, 95% CI 1.09-1.92, p=.01). CONCLUSION: In the current era, redo CABG is nearly as safe as the primary operation. A valve reoperation, on the contrary, is higher risk due, partly, to severe symptoms at presentation. Patients should be referred and operated on early before they develop severe symptoms.

Intensive care unit readmission after elective coronary artery bypass grafting.

Prospective data of 3,120 consecutive patients who had elective coronary artery bypass were analyzed to identify patient profile, cost, outcome and predictors of those readmitted to the intensive care unit. Group A (n=3,002) had a single intensive care unit admission and group B (n=118) were readmitted within 30 days after surgery. Parsonnet score, EuroSCORE, age, body mass index, chronic obstructive airway disease, peripheral vascular disease, renal dysfunction, unstable angina, congestive cardiac failure, and poor left ventricular function were higher in group B. Bypass and crossclamp times were longer, and the prevalence of inotropic and balloon pump support, arrhythmias, myocardial infarction, re-exploration, blood loss and transfusion, cerebrovascular accident, wound infection, sternal dehiscence, and multisystem failure were higher in group B. Despite a 4-fold increase in cost of care, the mortality rate (32.4%) of patients readmitted to intensive care was 23-times higher than routine patients (1.4%). Crossclamp time>80 min, Parsonnet score>10, EuroSCORE>9, sternal dehiscence, ventricular arrhythmias, and renal failure predicted readmission.

Long-term prognosis and a prediction model for acute bowel ischaemia following cardiac surgery.

OBJECTIVES: Bowel ischaemia following cardiac surgery is associated with a high postoperative mortality. No scoring system exists as yet to predict this complication following surgery. In addition, the long-term survival is not known. We sought to evaluate in-hospital outcomes and long-term outcomes in bowel ischaemia following cardiac surgery. We also sought to devise a simple risk prediction model for this catastrophic entity. METHODS: This was a retrospective study of data entered prospectively into our cardiac surgical database between July 1999 and May 2014. We compared the short- and long-term outcomes of patients who developed bowel ischaemia following cardiac surgery with those who did not develop bowel ischaemia using propensity-matched analysis. We developed a prediction model for bowel ischaemia from logistic regression. RESULTS: In total, 13 853 patients underwent cardiac surgery. Of these, 85 had confirmed bowel ischaemia following surgery. The in-hospital mortality rate for those with bowel ischaemia was 60%, while in those without bowel ischaemia, the mortality rate was 3% (P < 0.0001). In those bowel ischaemia patients who had a laparotomy for corrective surgery, the in-hospital mortality was significantly less compared with those who did not have a laparotomy (39.2 vs 91.2%, P < 0.0001). The long-term survival for bowel ischaemia at 2, 6 and 10 years was 35% (±5), 31% (±5) and 26% (+/6), respectively. Multivariable analysis revealed that advanced age at surgery, peripheral vascular disease, intra-aortic balloon pump usage, NYHA IV and postoperative atrial fibrillation were the significant (P < 0.005) determinants of developing postoperative bowel ischaemia. We developed a model to predict bowel ischaemia and validated it within our population (c-index = 0.781). CONCLUSIONS: We have shown that whilst bowel ischaemia carries a higher short-term mortality, the long-term mortality is not significantly greater for those few who survive to discharge. We have developed a simple prediction model to identify those at high risk of developing bowel ischaemia following cardiac surgery in order to optimize perioperative strategies in future.

Complex aortic surgery in a regional center in the United Kingdom. Should the United Kingdom now adopt a United States-style supercenter model?

BACKGROUND: The United States has established aortic supercenters, which have demonstrated clear improvements in the short-term and long-term outcomes after surgery on the thoracic aorta. This model of care does not exist in the United Kingdom. We have looked at our recent experience of emergency and elective thoracic aortic surgery and describe and compare our operative outcomes and 10-year survival with other regional centers and supercenters worldwide. METHODS: This was a retrospective analysis of data collected prospectively from our cardiac database on patients who underwent surgery on the thoracic aorta (n=318) between November 1999 and November 2012. The outcome measures were adjusted operative mortality, postoperative complications, and long-term survival. RESULTS: Type A dissection was carried out on 23.90% of the patients and 76.10% had surgery on the aortic root and thoracic aorta for nondissection. The mean age of the patients was 62.21±14.1 years. The mean logistic EuroSCORE was 26 in the dissection group and 19 in the nondissection group. Hospital mortality was significantly greater (P<.05) in the dissection group compared with the nondissection group (23.7% vs 12.8%). Survival after dissection and nondissection surgery was 66.3%±5.6% versus 77.4%±2.8%, respectively, at 3 years, 63.9%±5.9% versus 71.8%±3.2% at 5 years, and 53.7%±7.4% versus 47.1%±6.0% at 10 years. CONCLUSIONS: Our outcomes are comparable with other regional centers worldwide; however, they are not as good as those reported from the aortic supercenters. There should be continued impetus regarding the establishment of thoracic aortic surgery guidelines and specialist aortic centers in the United Kingdom.

Hyperoxic vasoconstriction of human pulmonary arteries: a novel insight into acute ventricular septal defects.

Objectives. Acute rises in pulmonary artery pressures following postinfarction ventricular septal defects present a challenge. We hypothesised that the abnormally high oxygen content exposure to the pulmonary arteries may be a factor. We investigated the contractile responses of human pulmonary arteries to changes in oxygen tension. Methods. Isometric tension was measured in large and medium sized pulmonary artery rings obtained from lung resections for patients with bronchial carcinoma (n = 30). Fresh rings were mounted in organ baths bubbled under basal conditions with hyperoxic or normoxic gas mixes and the gas tensions varied during the experiment. We studied whether voltage-gated calcium channels and nitric oxide signalling had any role in responses to oxygen changes. Results. Hypoxia caused a net mean relaxation of 18.1% ± 15.5 (P < 0.005) from hyperoxia. Subsequent hyperoxia caused a contraction of 19.2% ± 13.5 (P < 0.005). Arteries maintained in normoxia responded to hyperoxia with a mean constriction of 14.8% ± 3.9 (P < 0.005). Nifedipine inhibited the vasoconstrictive response (P < 0.05) whilst L-NAME had no effect on any hypoxic vasodilatory response. Conclusions. We demonstrate that hyperoxia leads to vasoconstriction in human pulmonary arteries. The mechanism appears to be dependent on voltage-gated calcium channels. Hyperoxic vasoconstriction may contribute to acute rises in pulmonary artery pressures.

Early and late prognostic significance of remote and reversible preoperative neurological events in patients undergoing coronary artery bypass grafting.

OBJECTIVES: Preoperative neurological event with functional impairment is high risk for operative morbidity and mortality after coronary artery bypass grafting (CABG). However, data regarding the influence of remote and reversible neurological events on early and late survival are lacking. METHODS: The clinical profile and operative outcome of 5542 patients who underwent first-time CABG from 01 April 1999 through 30 June 2008 were analysed. Late survival data were 100% complete. The relationship between preoperative neurological event and survival (early and late) was investigated using multivariate logistic regression and survival analyses. RESULTS: Mean age was 65.2+/-9.2 years, and 494 patients (8.9%) had remote reversible neurological events preoperatively. There were 129 (2.3%) operative and 595 (10.7%) late deaths after a mean follow-up of 4.9+/-2.7 years. Reversible neurological events had strong univariate (odds ratio (OR) 2.80, 95% confidence interval (CI) 1.82-4.33, p<0.0001) and multivariate associations (OR 2.14, 95% CI 1.34-3.41, p=0.001) with operative mortality. Although reversible neurological events exhibited a powerful univariate relationship with late deaths (hazard ratio (HR) 1.66, 95% CI 1.30-2.12, p<0.0001), this was not maintained after controlling for other factors in multivariable analysis (HR 1.24, 95% CI 0.97-1.59, p=0.08). Neurological complications, more frequent in patients with preoperative events, were implicated in 25% of operative deaths in patients with preoperative neurological events. The respective 5- and 10-year survival rates for patients with reversible neurological events (86% and 68%) were substantially lower than others (91% and 80%, p<0.0001). CONCLUSIONS: Remote reversible neurological events increase the risk of fatal and non-fatal postoperative neurological complications. Rigorous measures to improve cerebral protection are warranted in these patients.

To graft or not to graft? Do coronary artery characteristics influence early outcomes of coronary artery bypass surgery? Analysis of coronary anastomoses of 5171 patients.

OBJECTIVE: Small coronary size and extensive atherosclerosis pose operative challenges during coronary artery bypass grafting. We investigated the influence of coronary characteristics on early operative outcome. METHODS: Prospectively collected data for 5171 patients undergoing first-time coronary artery bypass grafting from April 1, 1999, to December 31, 2007, were analyzed. Coronary diameter estimated or probe-gauged intraoperatively was regarded as small if 1.25 mm or less. Coronary atherosclerosis was graded as none/mild or moderate/severe. Their influence on postoperative major adverse cardiac events, myocardial infarction or reintervention for graft failure, post-cardiotomy shock, and operative mortality, was investigated. RESULTS: Of 14,019 coronary anastomoses, 4417 coronaries (31.5%) were small and 5895 coronaries (43.4%) had moderate/severe atherosclerosis. All grafted coronaries were small in 1091 patients (21.1%). Left anterior descending, circumflex, and right coronary arteries received grafts in 94.8% of patients (n = 4903), 74.3% of patients (n = 3842), and 72.5% of patients (n = 3751), with corresponding rates of 31.7%, 31.7%, and 32.6% for small-caliber arteries, 44.4%, 33.3%, and 47.2% for moderate/severe atherosclerosis, and 0.6%, 0.5%, and 3.4% for endarterectomy. Postoperative major adverse cardiac events occurred in 236 patients (4.6%). There was no clear evidence that small caliber of half or more distal anastomoses in a patient (odds ratio, 1.36; 95% confidence interval, 0.97-1.94; P = .07) increased the risk of a major adverse cardiac event, but incomplete revascularization (odds ratio, 1.87; 95% confidence interval, 1.03-3.39; P = .04) and moderate/severe atherosclerosis of the left anterior descending artery (odds ratio 1.37; 95% confidence interval, 1.01-1.87; P = .04) did increase the risk. CONCLUSION: Grafting small coronaries did not significantly increase the risk of an early postoperative major adverse cardiac event, but incomplete revascularization did increase the risk. Our findings support grafting small coronaries when technically feasible to prevent incomplete revascularization.

Cardiopulmonary bypass and left ventricular systolic dysfunction impacts operative mortality differently in elderly and young patients.

OBJECTIVE: Cardiac surgery is higher risk in the elderly. It has been suggested that preoperative left ventricular systolic dysfunction (LVSD) and cardiopulmonary bypass (CPB) affect elderly and young patients differently. This study investigates the predictive risk of preoperative LVSD and CPB time for operative mortality in the two groups of patients. METHODS: We reviewed the data for 2616 consecutive patients aged >/=70 years and 4078 young patients who had coronary artery bypass grafting (CABG) and/or valve surgery between March 1998 and January 2007. Subgroups defined by severity of LVSD (ejection fraction >0.50 [mild], 0.31-0.50 [moderate] and

Non-infective morbidity in diabetic patients undergoing coronary and heart valve surgery.

OBJECTIVE: Studies of postoperative morbidity in diabetics have focussed on infection; however, autonomic and cardiovascular complications of diabetes potentially increase the risk for non-infective morbidity. We sought to investigate major non-infective early postoperative complications in diabetic patients. METHODS: We identified diabetics who underwent CABG and/or valve operation from 1998 through 2007, and compared their clinical characteristics and outcome with a contemporaneous cohort of non-diabetic patients. RESULTS: The demographic characteristics of 1145 diabetics were similar to 5534 non-diabetic patients (mean age 66+/-9 years vs 66+/-10 years, p=0.45, female 27.5% vs 26.7%, p=0.59, respectively). Class III/IV angina symptoms (43.9% vs 34.9%, p<0.0001), intravenous nitrates therapy (10.4% vs 6.6%, p<0.0001), heart failure (24.8% vs 20.4%, p=0.001), prior myocardial infarction (37% vs 31%, p<0.0001), ejection fraction

Early and late survival after surgical revascularization for ischemic ventricular fibrillation/tachycardia.

BACKGROUND: Ischemic ventricular fibrillation/tachycardia (VF/VT) treated by myocardial revascularization, often with an implanted cardioverter defibrillator, prevents sudden cardiac death. Early series have suggested that recurrent VF/VT threatens survival even after treatment. As late outcome is unknown, we sought to determine if the early survival benefit is sustained. METHODS: From January 1999 through January 2007, 93 consecutive patients (75 male, 81%) presented with ischemic VF/VT; 21% survived cardiac arrest and underwent coronary artery bypass graft surgery at our institution. We analyzed their early and late survival. RESULTS: Median age was 66 years (range, 44 to 88). Clinical presentation included class III/IV angina (46%), controlled heart failure (43%), prior myocardial infarction (68%), left ventricular ejection fraction less than 0.30 (23%) and 0.30 to 0.50 (35%), left main stem disease (24%), and triple-vessel disease (67%). Surgical revascularization, mostly nonelective (urgent 73%, emergency 7%), was combined with aortic valve replacement in 5 patients and left ventricular pseudoaneurysm repair in 3. Ischemic territories and mean number of diseased coronaries (2.6) corresponded to the grafted territories and average number of grafts (2.5). Operative mortality was 6.5% (n = 6, median EuroSCORE [European System for Cardiac Operative Risk Evaluation] predicted mortality 9). Recurrent VF/VT occurred early postoperatively in 21 patients (24%). All patients had electrophysiologic studies postoperatively and 40% received an implanted cardioverter defibrillator. Of 12 late deaths (16%) at follow-up extending to 8 years, 4 (33%) were due to cardiac causes. Five-year survival was 88%, equivalent to that (83% to 85%) reported for patients with sinus rhythm preoperatively. CONCLUSIONS: Complete myocardial revascularization for ischemic VF/VT yields excellent early and late results; 5-year survival is comparable to that of patients with preoperative sinus rhythm.

Changing operative characteristics of patients undergoing operations for coronary artery disease: impact on early outcomes.

BACKGROUND: Aggressive nonsurgical revascularization results in high-risk patients presenting for operation at a later stage of coronary artery disease (CAD). This study investigated the effect of temporal changes in operative characteristics on outcomes of surgical revascularization. METHODS: We compared preoperative, intraoperative, and postoperative variables of 5633 patients who underwent surgical revascularization for CAD between April 1998 and January 2007, divided into early (1998 to 2002, n = 2746) and late (2004 to 2007, n = 2887) eras. End points were major adverse outcomes (postoperative myocardial infarction, stroke, new dialysis) and operative mortality. RESULTS: Median age (66 vs 68 years, p < 0.0001), prevalence of left ventricular systolic dysfunction, left main stem disease, prior angioplasty, diabetes mellitus, concomitant valve operation, and aprotinin use increased steadily over time. Severe symptoms, nonelective operations, mean number of grafts, postoperative bleeding, reopening for bleeding, and blood transfusion declined. Major complications were evenly distributed between the eras. Operative mortality for isolated coronary artery bypass grafting did not change (2.0% vs 1.8% p = 0.62) despite increasing operative risk (p < 0.0001); there was a 100% reduction in the absolute risk (110% to 210%) over time. The markers for operative difficulties, such as longer bypass times, were determinants of operative mortality and, in addition to other predictors like age and left ventricular systolic dysfunction, were more prevalent in the late era. CONCLUSIONS: Coronary operations are increasingly performed in higher-risk patients; however, surgical revascularization is nearly twice as safe in current practice compared with a decade ago.

Aprotinin in primary cardiac surgery: operative outcome of propensity score-matched study.

BACKGROUND: Some recent multicenter series have questioned the safety of aprotinin in primary cardiac operations. We report a large, single-center experience with aprotinin therapy in primary cardiac operations and discuss the limitations and potential confounders of current treatment strategies. METHODS: We compared myocardial infarction, neurologic events, renal insufficiency, and operative death after first-time coronary or valve procedures, or both, in 3334 patients treated with full-dose aprotinin with 3417 patients not treated with aprotinin who underwent operation between March 1998 and January 2007. Further analysis was performed for 341 propensity score-matched pairs. RESULTS: There were substantial differences between the groups. Aprotinin patients were higher risk on account of older age, unstable symptoms, poor ejection fraction, preoperative hemodynamic support, emergency/urgent operations, and combined coronary/valve operations. Postoperative bleeding and blood product transfusion were considerably reduced in aprotinin patients, as was median duration of mechanical ventilation. Aprotinin was neither a predictor of postoperative myocardial infarction, renal insufficiency, neurologic dysfunction, or operative death. Achieving parity between the groups by propensity score matching eliminated the elevated rates of postoperative renal insufficiency, neurologic dysfunction, and operative death observed in aprotinin patients in the unmatched comparison. These adverse outcomes were evenly distributed between matched groups. Conversely, blood transfusion had univariate associations with all adverse outcome measures. CONCLUSIONS: Full-dose aprotinin use was not associated with myocardial infarction, neurologic dysfunction, renal insufficiency, or death after coronary or valve operations. We observed less postoperative bleeding and blood product transfusion, and early extubation with the use of aprotinin.